Overview on the National Tuberculosis Elimination Programme (NTEP)

National Tuberculosis Elimination Programme

Tuberculosis (TB) control activities are implemented in the country for more than 50 years. The National TB Programme (NTP) was launched by the Government of India in 1962 in the form of District TB Centre model involved with BCG vaccination and TB treatment. In 1978, BCG vaccination was shifted under the Expanded Programme on Immunization. A joint review of NTP was done by Government of India, World Health Organization (WHO) and the Swedish International Development Agency (SIDA) in 1992 and some shortcomings were found in the programme such as managerial weaknesses, inadequate funding, over-reliance on x-ray, non-standard treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes.

Around the same time in1993, the WHO declared TB as a global emergency, devised the directly observed treatment – short course (DOTS), and recommended to follow it by all countries. The Government of India revitalized NTP as Revised National TB Control Programme (RNTCP) in the same year. DOTS was officially launched as the RNTCP strategy in 1997 and by the end of 2005 the entire country was covered under the programme.

During 2006–11, in its second phase RNTCP improved the quality and reach of services and worked to reach global case detection and cure targets. These targets were achieved by 2007-08. Despite these achievements, undiagnosed and mistreated cases continued to drive the TB epidemic. TB was the leading cause of illness and death among persons living with HIV/AIDS and large number of multidrug resistant TB (MDR-TB) cases were reported every year. During this period for achievement of the long-term vision of a “TB free India”, National Strategic Plan for Tuberculosis Control 2012-2017 was documented with the goal of ‘universal access to quality TB diagnosis and treatment for all TB patients in the community’.

Significant interventions and initiatives were taken during NSP 2012-2017 in terms of mandatory notification of all TB cases, integration of the programme with the general health services (National Health Mission), expansion of diagnostics services, programmatic management of drug resistant TB (PMDT) service expansion, single window service for TB-HIV cases, national drug resistance surveillance and revision of partnership guidelines.

However, to eliminate TB in India by 2025, five years ahead of the global target, a framework to guide the activities of all stakeholders including the national and state governments, development partners, civil society organizations, international agencies, research institutions, private sector, and many others whose work is relevant to TB elimination in India is formulated by RNTCP as National Strategic Plan for Tuberculosis Elimination 2017-2025.

“National strategic plan for tuberculosis elimination 2017-2025“

RNTCP has released a ‘National strategic plan for tuberculosis 2017-2025’ (NSP) for the control and elimination of TB in India by 2025. According to the NSP TB elimination have been integrated into the four strategic pillars of “Detect – Treat – Prevent – Build” (DTPB).

DETECT

‘National strategic plan for tuberculosis elimination 2017-2025’- RNTCP has released a ‘National strategic plan for tuberculosis 2017-2025’ (NSP) for the control and elimination of TB in India by 2025. According to the NSP TB elimination have been integrated into the four strategic pillars of “Detect – Treat – Prevent – Build” (DTPB). DETECT: The first objective of NSP is to find all drug sensitive TB cases (DS-TB) and drug resistant TB cases (DRTB) with an emphasis on reaching TB patients seeking care from private providers and undiagnosed TB cases in high-risk populations (such as prisoners, migrant workers, people living with HIV/AIDS, contacts etc.).

Early diagnosis and treatment of TB cases in the community is an important step in TB elimination, which will help in decreasing the risk of transmission of disease to others, poor health outcomes, and social and economic hardships of the patient and their family.

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Notification of TB cases: Notification of all TB patients from all health care providers is made mandatory by Ministry of Health and Family Welfare, Government of India since 2012. All health care providers (clinical establishments run or managed by government (including local authorities), private, or NGO sectors, and /or individual practitioners) should notify every TB case to local health authorities (district health officer, chief medical officer of a district, and municipal health officer of a municipal corporation/ municipality) every month. With its amendment in 2015, all laboratories are also included to notify TB cases.

Till now, only medical practitioners, hospitals and laboratories were notifying TB patients to government health system, now according to ‘Mandatory TB notification Gazette for private practitioners, chemists and public health staff’ March 2018, all chemists will also inform about TB patients for whom they have dispensed the TB drugs. TB patients themselves are also encouraged to notify themselves. Every TB patient will be attempted to reach out by the local public health authority, namely, District Health Officer or Chief Medical Officer of a District and Municipal Health Officer of urban local bodies, so that the incentives and support to patients, families and communities can be properly extended.

NIKSHAY: To facilitate TB notification, RNTCP has developed a case-based web-based TB surveillance system called “NIKSHAY” (https://nikshay.gov.in) for both government and private health care facilities. Future enhancements under NIKSHAY are for patients support, logistics management, direct data transfers, adherence support and to support interface agencies which are supporting programme to expand the reach.

TREAT

Next step under the programme is initiation and sustaining all TB patients on appropriate anti-TB treatment wherever they seek care, with patient friendly system and social support. Provision of free TB drugs in the form of daily fixed dose combinations (FDCs) for all TB cases is advised with the support of directly observed treatment (DOT).

First line treatment of drug-sensitive TB consists of a two-months (8weeks) intensive phase with four drug FDCs followed by a continuation phase of four months (16 Weeks) with three drug FDCs.

For new TB cases, the treatment in intensive phase (IP) consists of eight weeks of Isoniazid (INH), Rifampicin, Pyrazinamide and Ethambutol (HRZE) in daily doses as per four weight band categories and in continuation phase three drug FDCs- Rifampicin, Isoniazid, and Ethambutol (HRE) are continued for 16 weeks.

For previously treated cases of TB, the Intensive Phase is of 12 weeks, where injection streptomycin is given for 8 weeks along with four drugs (INH, Rifampicin, Pyrazinamide and Ethambutol) and after 8 weeks the four drugs (INH, Rifampicin, Pyrazinamide and Ethambutol) in daily doses as per weight bands are continued for another four weeks. In continuation phase Rifampicin, INH, and Ethambutol are continued for another 20 weeks as daily doses.

The continuation phase in both new and previously treated cases may be extended by 12-24 weeks in certain forms of TB like skeletal, disseminated TB based on clinical decision of the treating physician.

Nikshya poshak yozana: It is centrally sponsored scheme under National Health Mission (NHM), financial incentive of Rs.500/- per month is provided for nutritional support to each notified TB patient for duration for which the patient is on anti-TB treatment. Incentives are delivered through Direct benefit transfer (DBT) scheme to bank accounts of beneficiary*.

PREVENT

1. Air borne infection control measures:- TB infection control is a combination of measures aimed at minimizing the risk of TB transmission within population and hospital and other settings. The foundation of such infection control is:
   • Early diagnosis, and proper management of TB patients.
   • Health education about cough etiquettes and proper disposal of sputum by patient. Cough etiquette means covering nose and mouth when coughing or sneezing. This can be done with a tissue, or if the person doesn’t have a tissue they can cough or sneeze into their upper sleeve or elbow, but they should not cough or sneeze into their hands. The tissue should then be safely disposed of.
   • Houses should be adequately ventilated.
   • Proper use of air borne infection control measures in health care facilities and other settings
2. Contact tracing:- Since transmission can occur from index case to the contact any time (before diagnosis or during treatment) all contacts of TB patients must be evaluated. These groups include:
   • In case of paediatric TB patients, reverse contact tracing for search of any active TB case in the household of the child must be undertaken.
   • Particular attention will be paid to contacts with the highest susceptibility to TB infection.
   • All close contacts, especially household contacts.
3. Isoniazid Preventive Therapy (IPT):- Preventive therapy is recommended to Children < 6 years of age, who are close contacts of a TB patient. Children will be evaluated for active TB by a medical officer/ pediatrician and after excluding active TB he/she will be given INH preventive therapy In addition to above, INH preventive therapy will be considered in following situation:
   • For all HIV infected children who either had a known exposure to an infectious TB case or are Tuberculin skin test (TST) positive (>=5mm induration) but have no active TB disease.
   • All TST positive children who are receiving immunosuppressive therapy (e.g. Children with nephrotic syndrome, acute leukemia, etc.).
   • A child born to mother who was diagnosed to have TB in pregnancy will receive prophylaxis for 6 months, provided congenital TB has been ruled out. BCG vaccination can be given at birth even if INH preventive therapy is planned.
4. BCG vaccination:- It is provided at birth or as early as possible till one year of age. BCG vaccine has a protective effect against meningitis and disseminated TB in children.
5. Addressing social determinants of TB like poverty, malnutrition, urbanization, indoor air pollution, etc. require inter departmental/ ministerial coordinated activities and the programme is proactively facilitating this coordination.